Psychotherapy Dip Paired with Spike in Antidepressant Use

Action Points

Explain to interested patients that earlier research had found that antidepressant use has increased markedly in recent decades.

Explain that this study was based on data from a large government-sponsored survey that included information obtained from patients and their medical providers, including pharmacies.

The number of Americans taking antidepressants soared during the decade from 1996 to 2005 -- from an estimated 13.3 million to 27 million -- and the use of psychotherapy plummeted, researchers found.

Data from the federal Medical Expenditure Panel Surveys in those years indicated that the percentage of Americans taking antidepressants nearly doubled, from 5.84% (95% CI 5.47% to 6.23%) in 1996 to 10.12% (95% CI 9.58% to 10.69%) in 2005, according to Mark Olfson, MD, MPH, of Columbia University in New York City, and Steven C. Marcus, PhD, of the University of Pennsylvania in Philadelphia.

After adjusting for demographic factors, income, insurance status, and self-perceived mental health, the researchers calculated that the rate of antidepressant use increased 68% (95% CI 55% to 81%) during that interval, they wrote in the August issue of Archives of General Psychiatry.

Over the same period, the percentage of respondents on antidepressants who also received antipsychotic medications increased substantially (from 5.46% to 8.86%, adjusted rate ratio 1.77, 95% CI 1.31 to 2.38).

These increases in drug use by depressed patients were accompanied by a sharp decrease in reported use of psychotherapy -- from 31.5% of respondents treated for depression in 1996 to 19.87% in 2005 (adjusted rate ratio 0.65, 95% CI 0.56 to 0.72).

"These trends vividly illustrate the extent to which antidepressant treatment has gained acceptance in the U.S. and the growing emphasis on pharmacologic rather than psychologic aspects of care," Olfson and Marcus wrote.

The survey data also indicated that African-Americans did not participate in these trends. Their adjusted rate ratio for antidepressant use in 2005 versus 1996 was a nonsignificant 1.13 (95% CI 0.89 to 1.44), the researchers found.

Antidepressant use was also far lower in blacks than in whites in both surveys: at 3.61% in 1996 and 4.51% in 2005 for African-Americans versus 6.48% and 11.96% in those years for whites (P<0.05 for blacks versus whites in both years).

The Agency for Healthcare Research and Quality conducted the Medical Expenditure Panel Surveys, with nearly 19,000 respondents in 1996 and about 28,500 in 2005.

In each survey year, an adult household member was questioned three times about healthcare utilization as well as health status, demographic, and socioeconomic information. Participants were asked to record health-related information in a diary that was reviewed at subsequent visits. Their medical providers were also contacted, with participants' consent, to supplement the participant self-reports.

The survey included questions about prescribed medications, including drug names and patterns of use. Medication data were also obtained from participants' pharmacies.

Psychotropic medications were classed as antidepressants, anxiolytics, mood stabilizers, stimulants, or antipsychotics. Antidepressants were further categorized as SSRIs, "other newer antidepressants" (including such drugs as venlafaxine, duloxetine, and bupropion), and tricyclics and other older antidepressants.

Except for African-Americans, all categories of patients showed similar strong increases in antidepressant use during the study period.

No major differences in the rates of increase were found when the researchers looked at employment status, income level, educational attainment, insurance status, marital status, age, or sex.

Olfson and Marcus also found that antidepressant use increased substantially among patients with other diagnoses besides depression (expressed as percentages of patients treated with antidepressants):

However, these were not necessarily the diagnoses for which antidepressants were prescribed, the researchers said.

The survey data did not themselves provide explanations for the increase in antidepressant use, but the researchers suggested several possibilities:

Publication of guidelines supporting antidepressant use for anxiety and other disorders as well as depression

Increased direct-to-consumer advertising for antidepressants -- ad expenditures rose from $32 million in 1996 to $122 million in 2005

Less stigma attached to psychiatric disorders and treatment

Increased prevalence of major depression

The researchers said the decline in psychotherapy may have been driven by economics, including higher out-of-pocket costs to patients and low third-party reimbursements to providers. "It is also possible that changes in patient perceptions of the effectiveness of antidepressants may have been a factor," they added.

The growing racial disparity in antidepressant use rates may reflect perceptions and attitudes toward depression treatment among African-Americans, Olfson and Marcus said.

"African-Americans may be less predisposed than Hispanics or non-Hispanic whites to use antidepressants," they wrote, citing an earlier study in which blacks "reported a stronger preference for counseling over medication" compared with white and Hispanic patients.

"Much remains to be learned about the roles of culturally mediated beliefs, attitudes, and social norms and physician factors in shaping racial/ethnic trends in antidepressant use," the researchers said.

In discussing limitations to the study, they noted that the survey may have failed to elicit full and accurate information on all members of respondent households and did not include several important categories of people, such as the homeless and institutionalized.

The study was funded by the Agency for Healthcare Research and Quality and by the National Alliance for Research on Schizophrenia and Depression.

During the last five years, Dr Olfson reported research support from the National Institutes of Health, the Agency for Healthcare Research and Quality, the American Foundation for Suicide Prevention, the National Association for Research on Schizophrenia and Affective Disorders, the New York State Office of Mental Health, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, and Ortho-McNeil Janssen Scientific Affairs, and has worked as a consultant for AstraZeneca and Ortho-McNeil Janssen Scientific Affairs.

Dr Marcus reported research support during the last five years from the NIH, the National Patent Safety Foundation, Bristol-Myers Squibb, Eli Lilly, AstraZeneca, and Ortho-McNeil Janssen Scientific Affairs.

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